ABOUT THE CENTER FOR HEALTH MARKET INNOVATIONS The Center for Health Market Innovations (CHMI) promotes programs, policies, and practices that make quality healthcare affordable and accessible to the world’s poor. Operated through a global network of partners since 2010, CHMI is managed by the Results for Development Institute (R4D) with support from the Bill & Melinda Gates Foundation, the Rockefeller Foundation, and UKaid. Details about more than 1,500 innovative health enterprises, nonprofits, policies, and publicprivate partnerships can be found online at HealthMarketInnovations.org.
ABOUT THIS REPORT This report was compiled by the CHMI team at Results for Development: Jeff Arias, Cynthia Charchi, Donika Dimovska, Allison Ettenger, Lane Goodman, Gina Lagomarsino, Jessica Muganza, Rachel Neill, and Kara Suvada, Christina Synowiec, and Susan Tewolde. CHMI’s regional innovation partners, listed below, contributed insights on new programs and practices.
RECOMMENDED CITATION Center for Health Market Innovations (Published March 2015), Highlights: Findings from 2015. Results for Development Institute, Washington, D.C. Available at HealthMarketInnovations.org.
MANAGED BY:
CHMI’S REGIONAL INNOVATION PARTNERS • ACCESS Health International: India* • Bertha Centre for Social Innovation & Entrepreneurship: South Africa* • BroadReach Healthcare: South Africa • Consultation of Investment in Health Promotion: Vietnam • Freedom From Hunger, Bolivia, Ecuador, Peru • Institute of Health Policy, Management & Research: Kenya, Rwanda, Tanzania, Uganda • Interactive Research & Development: Pakistan* • Mercy Corps: Indonesia • Philippine Institute for Development Studies: Philippines • Africa Capacity Alliance: Kenya* • Swasti Health Resource Centre: India* • Solina Health: Nigeria* • The Asia Foundation: Pakistan *Active during 2015
CONTACT CHMI AT R4D Results for Development 1111 19th Street, NW, Suite 700 Washington, D.C. 20036 1-202-470-5711 chmi@r4d.org
FOUNDING FUNDERS:
TABLE OF CONTENTS Welcome Letter........................................................................................................ 2 Why Focus on Improving Health Markets?............................................................. 4 Highlights of Developments in Health Markets...................................................... 6 Responding to Disasters........................................................................................ 8 Improving Adolescent Health................................................................................ 10 Paying for Health with Mobile Money.................................................................... 12 Shaping Health Markets and Harnessing Innovation............................................ 14 India..................................................................................................................... 16 Kenya................................................................................................................... 18 Pakistan................................................................................................................ 20 South Africa.......................................................................................................... 22 Nigeria................................................................................................................. 24 Promoting Learning and Collaboration for the Adaptation of Innovations........... 26 Tracking Program Performance.............................................................................. 34 CHMI’s Impact and Looking Forward...................................................................... 40
Health practitioners, donors, investors, policy makers, and academics rely on CHMI’s online platform. Photo: CCBRT | Patients in CCBRT’s Obstetric Fistula unit. The unit admits women of all ages living with fistula developed during prolonged labour, where they spend 2-3 weeks not only receiving life-changing surgery, but also having counseling, developing skills and supporting each other.
DEAR COLLEAGUES, CHMI was created in 2010 to enable health systems around the world to better utilize health market innovations with the goal of providing better quality, more affordable, and more accessible healthcare, especially for the poorest and most vulnerable. Health innovators, donors, investors, policy makers, and academics rely on CHMI’s online platform— documenting 1,500 health nonprofits, social enterprises, public-private partnerships, and policies— for insights on innovative health programs and analysis on developments in health markets. As the largest global public source of information on health innovations, CHMI actively supports collaborative learning to help promising programs improve, scale up, and adapt their models.
SOME OF OUR EXCITING HIGHLIGHTS FROM THE PAST YEAR INCLUDE • CHMI’s Primary Care Learning Collaborative published the Primary Care Innovator’s Handbook: Voices from Leaders in the Field to great success with over 2,500 downloads. The Handbook captures the experiences of primary care innovators from around the world, and has been used to facilitate cross-border collaboration between innovators. • CHMI’s Adaptation Framework for Global Exchange of Innovation is in use in South Africa, India, and the United States to support the transfer of promising practices to new contexts. The Framework has also shaped CHMI’s new learning and adaptation activities. • CHMI’s regional partners have worked on fostering increased collaboration and partnership between health innovators and government policymakers in Kenya, Nigeria, and India. • In early 2015, CHMI launched CHMI Plus, a system to make programs’ monitoring and evaluation practices readily available. With CHMI Plus, it is easy to search the CHMI database for innovations that share information on their activities, M&E strategies, and evidence of impact.
HIGHLIGHTS: FINDINGS FROM 2015
NEW IN THIS REPORT In this year’s edition of Highlights, we are excited to provide new insights on the universe of health innovations in our global database. • Explore how the market is evolving for several health areas. We examine how programs are responding to disasters, review how health innovators are addressing the needs of the growing global youth population, and look at the growing role of technology developed to pay for care. Page 12 • Discover the work of CHMI’s regional partners around the globe, and learn about their efforts to shape their countries’ health markets in order to benefit the poor. Page 14 • Read insights from our portfolio of work to foster learning and adaptation and promote the diffusion of promising practices across different contexts and geographies. Page 27 In 2015, CHMI underwent a strategic review of its work of the past five years. The review found that CHMI is an essential and relevant resource for the field and that its work achieves tangible results, informing policy and practice. Going forward, CHMI will continue working to improve health markets around the world through the diffusion of promising models that advance national and global health priorities. Read more on how we are applying the lessons of the past five years in our future work on page 41. We welcome your feedback on Highlights: Findings from 2015 and on our work to promote programs, policies, and practices improving the quality, affordability, and availability of healthcare for the poor.
Sincerely,
Donika Dimovska | ddimovska@r4d.org Results for Development Institute, On behalf of the CHMI network
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WHY FOCUS ON IMPROVING HEALTH MARKETS? The health market is where healthcare transactions are made by consumers and providers of services. These markets play a major role. In most developing countries, even where public facilities offer care free of charge, the poor rely on private providers operating within the health market for a large portion of their care. Health markets offer both challenges and opportunities. Patients do not always seek the kind of care that will make them healthier, and providers do not always act in the patients’ best interest. Appropriate care can be expensive, and out-of-pocket payments can push people further into poverty. However, health markets can also be a source of creative new approaches that offer the potential to achieve greater efficiencies, better quality, and increased access to care.
WHAT ARE HEALTH MARKET INNOVATIONS? Health market innovations are programs, practices and policies—implemented by governments, nongovernmental organizations (NGOs), social enterprises, or private companies—that seek to improve the availability and affordability of quality care for the poor.
HOW DOES CHMI IMPROVE HEALTH MARKETS?
WHAT KINDS OF PROGRAMS ARE INCLUDED IN CHMI’S PROGRAMS DATABASE? CHMI profiles programs that work in low- and middle-income countries (LMICs), serve lowincome communities, and work with health market innovations—harnessing innovation to deliver health services, finance care, or monitor their performance. All of CHMI’s data on innovative programs are public. Details about innovative health enterprises, nonprofits, policies, and public-private partnerships in low- and middle-income countries can be found online in the free, interactive programs database at HealthMarketInnovations.org. Through the database, research publications, in-person facilitated learning events, and strategic in-country and global partnerships, CHMI collects and disseminates information, conducts analysis, and creates connections between people implementing, funding, and studying innovative health programs.
CHMI promotes innovative programs, policies, and practices that improve healthcare and health markets. Operated through a global network of partners since 2010, CHMI is managed by Results for Development (R4D), an international nonprofit seeking innovative solutions to a range of development challenges. Our vision is for health systems around the world to better utilize health market innovations to deliver quality, affordable, and accessible care, especially for the poorest and most vulnerable.
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Our vision is for health systems around the world to better utilize health market innovations. Photo: D-Tree International | A community health worker in Zanzibar weighs a child at an Under 5 clinic.
HIGHLIGHTS OF DEVELOPMENTS IN HEALTH MARKETS
Over the past year, CHMI’s database has grown to include 1,500 profiles of innovative health programs in 130 countries. Explore the database in full at HealthMarketInnovations.org/programs. The majority of programs selected for this report, and for other CHMI benefits, are those with a CHMI Plus “GOLD” rating. These programs share updates on their activities and results, and share Monitoring and Evaluation information to help others improve. Learn how to improve your program rating at HealthMarketInnovations.org/CHMIPlus. CHMI’s database reveals how health markets in LMICs continue to evolve over time. Since 2010, we have analyzed programs across different health topics, geographic locations, legal structures, and many other dimensions to explore these changes and developments. For example, a key development is the
growth of documented for-profit enterprises, which now comprise 28% percent of CHMI-profiled programs. This may be due to the fact that CHMI has prioritized the documentation of market-based models (many of which tend to be for-profits)—however, it may also indicate a general rise of for-profit business models over the past five years. This is a broad trend that we continue to track and analyze. A second example is the rise of technology-enabled models. Technology has emerged as a major influence on services provided by programs launched in the past five years. The expanding role of technology in health is rapidly opening new interventions such as telemedicine, call centers, and healthcare hotlines. The proportion of programs using technology to virtually connect with patients is 12% higher for programs launched in the 2010-2015 period than for programs launched prior to 2010.1
A CHANGING LANDSCAPE IN HEALTH MARKETS Not for Profit For Profit
75%
The percentage of newer programs profiled on CHMI which identify as not-for-profit has decreased, while for-profit programs have grown.
The share of programs profiled on CHMI that were launched after 2010 which are offering virtual healthcare services compared to those providing care in person has changed.
67% 52%
48% 36%
50% 25%
Launched Prior to 2010 Launched 2010-2015
28%
26% 14%
13% Legal Status of Programs Profiled in the CHMI Database Launched Prior to 2010
Profit Status of Programs Profiled in the CHMI Database Launched 2010-2015
Percent of Programs Connecting Patients and Providers in Person in the Community
Percent of Programs Connecting Patients and Providers Virtually
In the sections that follow, CHMI explores how the health market is evolving for several health areas. This evolution reflects the changing landscape of challenges and priorities in LMICs’ health systems. This year we look at the growing global challenge in responding to natural and man-made emergencies. We also recognize the pressing need to address the health needs of a rapidly growing global youth population, as well as the growing role of technology in paying for health services. Harnessing new solutions to address these and other priority challenges will be a main focus for LMICs’ health systems in the coming years.
Photo Left: Telerad Foundation | A doctor using TeleRad’s telemedicine system to remotely screen patients in a rural setting. It is important to note that the CHMI dataset is not representative of all healthcare programs and may be biased for particular geographic regions and market-based models. The data should be interpreted as a sampling of programs—and only those that meet our specific inclusion criteria. 1
HIGHLIGHTS: FINDINGS FROM 2015
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HIGHLIGHTS OF DEVELOPMENTS IN HEALTH MARKETS
RESPONDING TO DISASTERS Millions of people around the world are injured, killed, or left homeless as a result of natural or man-made disasters and emergencies. Increasingly, health policymakers around the world focus on creating more resilient health systems. The CHMI database documents 32 programs that respond to a variety of emergencies ranging from disease outbreaks to natural disasters such as earthquakes. Most of these programs are based in East Asia, and many provide psychological counseling to disaster victims and utilize information and communication technology to track epidemics and diseases. For example, primary healthcare programs like Last Mile Health in Liberia and Possible Health in Nepal were uniquely equipped to respond to disasters in their countries of operation in recent years. Last Mile Health’s innovative approach to training and organizing frontline health workers allowed the organization to reach remote areas of northern Liberia severely affected by Ebola. Possible Health’s infrastructure in rural areas of Nepal enabled the organization to provide victims of the April 2015 earthquake with supplies and doctors.
COMMON DISASTER RESPONSE APPROACHES INCLUDE: RESPONDING TO DISEASE EPIDEMICS Eighteen programs documented by CHMI provide services to communities in the wake of disease outbreaks; this includes programs that monitor epidemics to prevent further spread of disease. ReliefWatch is a cloud-based medical supply and disease tracking platform that uses automated voice calls and simple mobile phones to reduce shortages in the supply of essential medicines in Honduras,
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Mozambique, Nicaragua, and Panama. The system provides real-time data to reduce medical stock-outs and expirations, and has the ability to track diseases to prevent an outbreak from turning into an epidemic. Surveillance in Post Extreme Emergencies and Disasters (SPEED) is a Philippines-based early warning disease surveillance system for post-disaster situations launched by the Philippine Department of Health and the World Health Organization in 2010. Health
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FOCUSING ON COMMUNITY RECOVERY Media Campaign PULIH, founded in 2003, plays a strategic role in supporting the mental health of the survivors of post-disaster and violent conflicts. The campaign trains media companies, journalists, and other mass media stakeholders about the repercussions of media coverage on the mental health of trauma victims. The campaign staff provides education on trauma recovery through mass media, including radio, magazines and newspapers. They also use social media to connect communities, activists, and the general public to promote safe mental health.
INSURING AGAINST CATASTROPHES
workers in evacuation areas conduct consultations with patients, where they complete reporting forms and enter the information into the SPEED system using SMS. SPEED then identifies potential disease outbreaks for health managers, local chief executives, and other individuals so they may take further action. In Cambodia, Smart Mobile is a wireless operator that provides low-cost access to SMS applications, such as GeoChat, to the Ministry of Health and NGOs in order to respond to infectious disease outbreaks in a timely manner. GeoChat can be used by public health officials with smart phones to establish group chats, share reports of information from the field, and send targeted alerts.
In Haiti, Microinsurance Catastrophe Risk Organization (MiCRO) Cholera Product works with microfinance institutions, like Fonkoze, to provide their clients with access to insurance to cover losses from catastrophic events, such as cholera outbreaks. In Haiti, Fonkoze has already started making catastrophe coverage available to its 50,000 clients. The scheme ensures “real-time” payout once a predefined set of criteria is met (e.g. cholera-related hospital admissions, observable weather factors linked to cholera outbreaks, etc.)
COMMON PRACTICES OF DISASTER RESPONSE PROGRAMS
DEPLOYING MOBILE TECHNOLOGY 21 out of the 32 disaster response programs identified use mobile technologies, such as telemedicine and GPS mapping, to provide health services to disaster victims. One innovation profiled in CHMI’s database is AMD’s Dispatch Case, a lightweight, easily portable device containing several telemedicine peripherals. Volunteers use the device to connect with physicians in the U.S. who provide immediate medical consultations to disaster victims. Disaster Logistics Relief, an NGO, used the Dispatch Case to virtually connect survivors of Typhoon Haiyan in 2013 and the Indian Ocean Tsunami in 2004 with US-based doctors.
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PROVIDE RESPONSE AFTER DISEASE OUTBREAKS
USE MOBILE TECHNOLOGY
Photo Left: Possible Health | Clinical and community health staff gather outside the Outpatient Department of Bayalpata Hospital for a meeting. Photo Right: Last Mile Health | Alice Johnson, RN, traveled for several days on motorbikes and on foot over hundreds of miles to establish primary care services in remote rainforest communities in Rivercess County, Liberia.
HIGHLIGHTS: FINDINGS FROM 2015
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HIGHLIGHTS OF DEVELOPMENTS IN HEALTH MARKETS
IMPROVING ADOLESCENT HEALTH In 2014, the world’s population was composed of nearly 1.8 billion young people, 90% of whom lived in LMICs.2 Adolescents everywhere face many challenges as they go through major physical and mental development. However, adolescent health is an oft-neglected topic in global health and the burden of disease among adolescents has not reduced significantly over the past decades.3 For many countries, ensuring the health and productivity of their future workforce will be a major priority in the coming years. CHMI’s database features nearly 300 programs delivering health services to adolescents. FOCUS AREAS FOR ADOLESCENT HEALTH: REPRODUCTIVE HEALTH AND FAMILY PLANNING Reproductive health issues are a leading cause of mortality among adolescents in LMICs. Approximately half of the 298 programs in CHMI database that work with adolescents and young people offer services in reproductive health and family planning. Many of these programs focus on tackling barriers to consumer awareness on sexual and reproductive health (SRH), particularly related to cultural and gender norms that may prevent adolescents from accessing needed services.
The Youth Truck in Uganda is a mobile outreach service which educates youth in rural areas and urban slums on SRH and rights, including HIV/AIDS prevention through film screenings, youth clubs, and games. In Kenya, I-Care seeks to empower girls by providing them with high-quality affordable and reusable sanitary towels to improve school attendance and self-esteem. Similarly, BanaPads and ZanaAfrica in Kenya sell ecofriendly sanitary pads, and train community members as saleswomen who deliver products and messages on menstrual hygiene and family planning door-to-door.
Photo: BanaPads | Students learning about menstrual pads. State of World Population. United Nations Population Fund (UNFPA), 2014 Every Woman, Every Child: Strengthening Equity and Dignity through Health. iERG, 2013 4 iERG, Ibid. 2 3
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Young people living with disabilities also require access to reproductive health and family planning services. Using Your Hands to Talk about Sex in Vietnam developed a sexual and reproductive health curriculum in sign language for deaf students.
HIV/AIDS HIV/AIDS is a major focus area for adolescent health, and 128 programs in the CHMI database focus on this issue for youth. Today, globally one in seven individuals is infected with HIV during adolescence (10-19 years old). In LMICs, where most of the HIV burden is concentrated, adolescents account for almost 40% of new HIV infections.4
Project Khuluma in South Africa provides mobile phone peer-to-peer support groups for HIV-positive adolescents to help them manage the day-to-day challenges that many of them face such as stigma and discrimination. The Sizophila Project, also in South Africa, provides training to unemployed and HIV-positive community members and employs them as therapeutic counselors. Counselors ensure antiretroviral therapy adherence and provide education and support to others who have been diagnosed with HIV, including adolescent and pediatric patients.
INNOVATIVE APPROACHES TO ADOLESCENT HEALTH: BEHAVIORAL CHANGE THROUGH CONSUMER EDUCATION AND SOCIAL MARKETING 235 programs use a behavioral change approach to address adolescent health through consumer education and social marketing strategies. In Vietnam, the Youth CafĂŠ is a chain of coffee shops where peer educators and health experts discuss reproductive health and life skills with the adolescent population. These experts also distribute posters and leaflets on HIV, sexually transmitted infections (STIs), and reproductive health to young clients. Matibabu Foundation in Kenya is a community initiative that aims to reach the most underserved youth in rural areas and engage them in health education and counseling programs on HIV, SRH, and cervical cancer. Matibabu also offers an integrated continuum of services through its main clinic.
ENHANCING PROCESSES THROUGH ICT 85 programs in the CHMI database focus on harnessing information and communication technology (ICT) for adolescent health. Adolescents who go to clinics may be scared or embarrassed to ask questions related to reproductive health as a result of the stigma associated with these services, or a lack of confidentiality and/or accurate information from providers. Virtual services offer an avenue for youth to have conversations with experts and peers without the fear of being exposed. Partners in Reproductive Health (PIRH), based in Kenya, hosts the Stay Alive Youth radio program, where guest speakers answer questions on SRH. Similarly, 100% Jeune in Cameroon and Window of Love in Vietnam are call-in radio programs that use drama series and peer education sessions to promote condom use and SRH education.
FOCUS AREAS AND PRACTICES OF ADOLESCENT HEALTH PROGRAMS
235
85
128
48%
BEHAVIOR CHANGE THROUGH CONSUMER EDUCATION AND SOCIAL MARKETING
INFORMATION COMMUNICATION TECHNOLOGY
HIV/AIDS
REPRODUCTIVE HEALTH & FAMILY PLANNING
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HIGHLIGHTS OF DEVELOPMENTS IN HEALTH MARKETS
PAYING FOR HEALTH WITH MOBILE MONEY Adoption of mobile money, or financial transactions conducted using a mobile phone, is rapidly growing as a means to improve the efficiency, management, and transparency of paying for health services. Thirtyfour programs in the CHMI database use mobile money as a key part of their program. FOCUS AREAS FOR PROGRAMS USING MOBILE MONEY INCLUDE: ELECTRONIC VOUCHERS (EVOUCHERS)
MICRO-INSURANCE THROUGH PHONES
The use of electronic vouchers, transferred through mobile phones, has been documented in seven CHMI-profiled programs. Generally, eVouchers are transferred from clinic to patient to shop, after which, the shop (such as a pharmacy) redeems the e-voucher with the original clinic or health program. The eVoucher represents real value to the shopkeeper, and can be traded in for cash.
Eight programs in the CHMI database are using mobile money to facilitate micro or community-based health insurance payments. The Dengue Fever Insurance Card of Indonesia allows beneficiaries to purchase the card at participating vendors for a low cost. To claim their insurance, customers text their pin number from the purchased card to an SMS center which follows through with verification and payout.
MEDA Bednets, for example, issues eVouchers for bed nets to protect pregnant women from malaria to expectant mothers during health clinic visits. The eVouchers can be presented at any of over 5,500 participating retailers in Tanzania. MEDA then reimburses vendors for the collected eVouchers. The consumer pays part of the cost of the net’s value to promote ownership and use.
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PAYMENTS FOR HEALTH PROGRAMS AND COMMODITIES CHMI documents six different health service chains and networks which have adopted mobile money to manage the flow of funds towards health services or commodities within their organization.
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BlueStar Pilipinas reported to CHMI that this mobile money system has allowed them to greatly improve finance tracking and to streamline operations.
BlueStar Pilipinas, a family planning franchise run by licensed midwives in the Philippines, uses mobile money to make payments for stock orders, such as contraceptives, and for membership dues from franchisees paid weekly through their phones. BlueStar Pilipinas reported to CHMI that this mobile money system has allowed them to greatly improve finance tracking and to streamline operations.
REFERRALS THROUGH FINANCIAL INCENTIVES Two programs working independently from one another in Tanzania are using mobile money to improve referrals by offering money transferred through mobile phones to healthcare workers and/or volunteers for referring patients with specific conditions to their organization. Comprehensive Community Based Rehabilitation in Tanzania (CCBRT) partners with “ambassadors”— mainly health workers but also volunteers - throughout Tanzania to identify women suffering from fistulas. The ambassador makes the initial call to CCBRT, at which point the organization transfers funds to the ambassador to cover the woman’s cost of transportation to the health center. Once the woman arrives, CCBRT transfers an additional 5,000 Tanzanian shillings (US $3.50) to the ambassador as a gesture of appreciation and an incentive to seek out and send additional fistula patients for care.
D-Tree International uses mobile money with traditional birth attendants to refer women with obstetric emergencies for delivery in healthcare facilities, compensating them for lost income and providing additional funds to encourage future referrals. For more information on the use of mobile money to pay for health, visit CHMI’s Mobile Money topic page.
HEALTH PROGRAM USES FOR MOBILE MONEY 8 MICRO-INSURANCE THROUGH PHONES
11 OTHER
34 PROGRAMS 7 ELECTRONIC VOUCHERS 2 REFERRAL IMPROVEMENTS
6 PAYMENT FOR HEALTH SERVICES WITH MOBILE MONEY
Photo Left: Ueli Litscher, courtesy of D-Tree International | A family planning community health worker provides services to a client in Shinyanga, Tanzania Photo Middle: CCBRT | Dr. Brenda D’Mello from CCBRT’s Maternal & Newborn Health Capacity Building Program leading CPR training at one of CCBRT’s 22 partner facilities in Dar es Salaam
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SHAPING HEALTH MARKETS AND HARNESSING INNOVATIONS 14
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CHMI partners with a global network of country-based institutions, each working to scale the impact of health innovations in their countries and regions. When CHMI launched in 2010, we sought to engage in countries with vibrant mixed (public and private) health systems where health innovations could be found. CHMI helped to foster a global network of in-country organizations that act as facilitators of key local and regional actors, carrying out the dual role of connecting programs to opportunities, and encouraging system-level changes in health markets. Over the past five years, CHMI has worked with over fifteen institutions around the globe, including country partners in India, Kenya, Pakistan, Nigeria, and South Africa in 2015.
their peers and build new connections to tackle tough challenges impeding scale. They also act as a resource for investors, donors, and researchers to identify innovations with evidence of impact and potential for success. Policymakers at the local, national, and regional levels are looking to CHMI country partners for help in navigating private sector-led innovations, finding programs that support national priorities, and developing new public-private partnerships. Country partners serve as cornerstones of CHMI’s global network, helping us to improve the way health markets function to meet national health priorities.
CHMI country partner activities directly correspond to the specific needs expressed by governments and innovators. For example, partners develop opportunities for innovators to better connect with
Read more for a closer look at country level trends, new innovations, and our work to shape health markets to improve access and affordability to quality care for the world’s poor.
Photo Left: SalaUno | SalaUno offers eye care modeled after the Aravind model. Photo Below: mPedigree Global Image Archives | A pharmacist points out the mPedigree Goldkeys feature on a pack of antibiotics.
HIGHLIGHTS: FINDINGS FROM 2015
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SHAPING HEALTH MARKETS AND HARNESSING INNOVATIONS
INDIA COUNTRY OVERVIEW Extending health services to the 250 million people living below the poverty line in India is no easy task. Whether scattered across the country’s massive rural terrain or densely clustered in urban centers, both access to and the affordability of services is a challenge. According to WHO estimates in 2010, approximately 71% of all spending in healthcare was private, but about 86% of this spending was out-of-pocket, which risks pushing the poor further into poverty. Social entrepreneurs and state level governments are jointly rising to the challenge, making India a vibrant testing ground for health market innovations.
A LOOK AT THE FACTS CHMI profiles 279 programs across India, many tackling primary care and maternal, newborn, and child health (MNCH) challenges. For example, Ross Clinics operates with a holistic family doctor model, providing primary care as well as dental and physiotherapy services in central locations for target communities. By making preventative care accessible, Ross Clinics reduces the overall healthcare cost for each family. LifeSpring Hospitals Private Limited is an expanding
healthcare chain that provides MNCH services in Andhra Pradesh. Most deliveries are managed by midwives, which has made the costs of LifeSpring’s services 30-50% lower than prevailing market rates. The majority (82%) of the India-based programs in CHMI’s database operate in rural areas, including 44 mobile clinics. In Madhya Pradesh, Deen Dayal Chalit Aspatal uses GPS-enabled vans staffed with a doctor, nurse, lab attendant, and pharmacist to provide basic healthcare to rural populations. Lifeline Express Hospital Train is a mobile hospital train that relies on India’s extensive rail network to reach rural populations. Based on the success of mobile health programs, the state government has decided to incorporate mobile medical units into its National Rural Health Mission program. Programs are also relying on technology to reach rural populations. World Health Partners’ rural SkyCare and SkyHealth Centers are connected to specialized doctors in cities through video conferencing technology on computers. The Telerad Foundation provides radiology services for remote or underserved hospitals in Asia that are unable to provide them on-site, relying on technology to send diagnostic reports to hospitals across the region.
HEALTH PROGRAM FINANCING IN INDIA 10 SELF-FUNDED (BOOTSTRAPPED)
52 UNKNOWN
73 FOR PROFIT 79 REVENUE
PROFIT STATUS
FUNDING SOURCES
14 INVESTOR CAPITAL
110 DONOR 50 GOVERNMENT
16
154 NOT FOR PROFIT
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CHMI IN INDIA CHMI’s partners in India have been hard at work connecting innovators to new opportunities and facilitating the development of new publicprivate partnerships.
CONNECTING INNOVATORS TO FACILITATE SCALE—SWASTI In partnership with CHMI since 2013, Swasti, a not-for-profit health resource center, specializes in providing customized technical assistance to programs. The organization’s work includes identifying promising opportunities for programs, making timely linkages between stakeholders, exploring nascent thematic areas and providing long-term mentoring for program implementation. This year, Swasti focused on providing one-onone high impact technical support for six CHMIprofiled programs, with the goals of improving their sustainability and positions in the health market and ensuring the affordability and accessibility of their services for their target customers. Swasti facilitated 10 successful connections between these six programs and chosen partners. For example, Sevamob is a mobile primary care program based on a subscription model. By connecting Sevamob to organizations including SOS Children’s Village and Fullerton, their services have been expanded to 8000 more patient consultations per month in Delhi, Haryana, Bangalore, Chattisgarh, Madhya Pradesh and Andhra Pradesh.
of Andhra Pradesh, Telangana, and Rajasthan for advancing public healthcare goals through private sector engagement. In Andhra Pradesh and Telangana, ACCESS Health supported the states’ newly formed National Urban Health Mission. The “Catalyst for Change” program conceptualised by the states included partnerships with innovative primary care providers to act as model urban primary health centers, providing a performance benchmark for the urban primary care centers in that state. As a result of this work, ACCESS Health is working closely with 14 CHMI-profiled programs on new public private partnership proposals with the states. For example, Nationwide, a primary care program that uses a subscription-based payment mode, will take over a select portion of Andhra Pradesh’s public facilities, while LifeCircle Senior Services will support the state’s senior care services. Building on this approach, ACCESS Health replicated the process in the nearby state of Telangana. ACCESS Health is developing a PPP proposal between Karuna Trust (a primary care program) and the state that will allow the trust to manage 12 primary health centers. This work ultimately has the potential to impact 50 new and 250 existing urban primary healthcare centres in Andhra Pradesh, as well as serve as a model for neighbouring states looking to restructure their primary care services.
SUPPORTING GOVERNMENTS TO ENGAGE WITH THE PRIVATE SECTOR—ACCESS HEALTH INTERNATIONAL CHMI has been working in partnership with ACCESS Health International since 2010 to improve the diffusion of promising innovations in India through government partnerships. In 2015, ACCESS Health became a principal advisor to the Governments
Photo: Biocon Foundation| A community health worker explains facilities at a geriatric camp in a slum.
INDIA HEALTH PROGRAMS BY FOCUS Primary and Secondary Care Maternal & Child Health Noncommunicable Diseases Family Planning & Reproductive Health HIV/AIDS TB Malaria 20
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KENYA COUNTRY OVERVIEW With a rapidly growing population of over 40 million and a GDP of nearly 61 billion USD, Kenya boasts a dynamic public sector eager to partner with the private sector to advance national-level policy changes. But Kenya’s health market remains both highly fragmented and crowded with a plethora of smaller-scale providers. The country struggles with a critical shortage of physicians, with just one doctor per 10,000 residents. Moreover, Kenya also suffers from high maternal mortality (400 mothers per 100,000 live births) and infant mortality (48 children per 1,000 live births) rates.5 As a result, an increasing number of public and private sector actors have emerged to test new innovative approaches to healthcare delivery.
A LOOK AT THE DATABASE The CHMI Database currently profiles 209 programs from Kenya—the most of any African nation in the database. Of these, 157 target the poorest quintile of the Kenyan population. Kenya has one of the highest cell phone penetration rates in Africa, with over 80% of the population owning a mobile phone6, and 69 programs report using mobile phones in their operations. TotoHealth, for example, uses an SMS-based platform to allow parents and caregivers to record milestones in their child’s physical development, which helps with the timely detection of abnormal growth. M-Chango is a mobile based system that creates awareness of child immunization schedules and provides basic health information. WelTel aims to improve health outcomes such as adherence and retention through automated SMS messages to support patients on antiretroviral therapy, preventing mother-to-child transmission of HIV, and tuberculosis (TB) treatment. Micro and community-based insurance schemes and public sector insurance innovations can shield lowincome populations from health-related bankruptcy.
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MicroEnsure is an insurance intermediary that designs and implements insurance for the poor by offering an affordable range of insurance products. It uses a sophisticated management information system to track details of clients covered, collect premiums, and administer claims. The program also negotiates with insurance companies on behalf of their clients to keep premiums to a minimum. Health service chains and networks are able to reduce fragmentation and informality of healthcare delivery. Kenya’s Nairobi Slums TB Project relies on a team of 60 volunteer Community Health Workers (CHW) to test for TB cases in Nairobi’s slums, in order to improve prevention and treatment-seeking behavior. Viva Afya is a primary healthcare company that uses a “hub-and-spoke” model to serve densely-populated, low-income areas. A main clinic (hub) is supported by several electronically-connected satellite clinics (spokes). Clinical officers and nurses at the satellite clinics can seek advice from doctors at the main clinic through telephone and instant messaging, and refer patients to the main clinic as needed.
CHMI IN KENYA From 2014 through 2015, CHMI’s East Africa Partner, the Africa Capacity Alliance (ACA), convened a series of four roundtable discussions which brought policymakers, county health officials, development partners, investors, and health innovators together in one room to discuss best approaches to strengthen the health market ecosystem for MNCH in Kenya. The roundtables produced a comprehensive situational analysis of MNCH innovations in Kenya, and a deeper understanding of the importance of public private partnerships in improving the state of MNCH services in Kenya. The round tables also established linkages between Kenyan county governments, innovations, and funders. For example, Meru Country linked with Mobile ODT, a cost-effective cervical cancer screening tool from Israel, and Kakamega and Bungoma counties made a specific request for TotoHealth to be implemented in their counties.
http://databank.worldbank.org/data/reports.aspx?source=2&country=KEN&series=&period= http://www.pewglobal.org/2015/04/15/cell-phones-in-africa-communication-lifeline/
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“An “ increasing number of public and private sector actors in Kenya have emerged to test new innovative approaches to healthcare delivery
HEALTH PROGRAM FUNDING IN KENYA 2 IN-KIND CONTRIBUTION
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KENYA HEALTH PROGRAMS BY FOCUS Primary and Secondary Care HIV/AIDS Maternal & Child Health Family Planning & Reproductive Health TB Malaria Noncommunicable Diseases 20
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PAKISTAN COUNTRY OVERVIEW Pakistan has struggled for decades to overcome the challenges of access to healthcare, both physical and financial. Rural communities in Pakistan face great obstacles in receiving healthcare, as evidenced by significantly higher rates of maternal, under 5, and infant mortalities compared to urban populations.7 However, a look at programs in Pakistan reveals a vibrant community of innovators making use of technology to overcome these obstacles in delivering healthcare to the very last mile.
A LOOK AT THE DATABASE CHMI profiles 52 programs in Pakistan—38 are delivering care to rural communities, where 62% of Pakistan’s population lives.8 Sehat Sahulat Clinic Basic+ has taken its MNCH Services on the road, retrofitting an Isuzu truck into a mobile health clinic to reach rural areas not covered by public or private healthcare providers. The truck includes an examination room, laboratory, and pharmacy. DoctHERs is a novel healthcare marketplace that
connects female doctors to underserved patients through a telemedicine model. Patients visit primary health centers, located in underserved rural communities, which are staffed by female community health workers and connected via internet-enabled video conferencing to female doctors in urban areas. In addition to increasing accessibility for patients, doctHERs’ telemedicine approach also circumvents sociocultural barriers that restrict female doctors’ inclusion in the medical profession. Overcoming financial barriers to accessing care is also a major focus of innovators in Pakistan. Al-Shifa Trust is a not-for-profit and non-governmental entity that seeks to provide high quality ophthalmology (eye care) to all of Pakistan’s population; 70% of total patients have been treated free of cost due to the hospital’s cross-subsidization model. Heartfile Health Equity Financing seeks to prevent catastrophic health spending by low-income families. The model utilizes an IT-supported, automated demand side health financing instrument that can be accessed by local healthcare workers to seek urgent support for patients, who receive cash transfers to underwrite the cost of major medical expenses.
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CHMI IN PAKISTAN
mini aquariums that serve as reminders to patients on chronic medication.
Innovators in Pakistan face similar challenges to their peers elsewhere, but programs often lack the opportunity to share their lessons learned or document best practices. Beginning in 2013, Interactive Research and Development (IRD), in partnership with CHMI, responded to this knowledge gap by developing the CHMI-IRD Innovations Hub in Pakistan. The Hub is an interactive initiative that brings together organizations from across the spectrum of healthcare delivery in Pakistan to share their lessons learned, replicate and scale promising health market innovations, and promote linkages between organizations.
The CHMI-IRD Innovations Hub has also setup a platform to assist more developed public health initiatives that are facing management and operational obstacles to achieving scale. The Health Management Innovations Series brings together some of the largest non-profit organizations in Pakistan where creative professionals encourage “out-of-the-box� thinking to overcome roadblocks to growth and sustainability.
Building on the excitement generated by the CHMI-IRD Innovations Hub, IRD sponsored the development of a health innovation prize in collaboration with the I Am Karachi initiative in 2015. The Innovation Challenge enabled public health issues to be highlighted at a high-profile event in Karachi, and provided creative individuals an opportunity to propose innovative solutions to problems their communities face on a daily basis. Garnering significant interest and over 700 applications, the IRD team facilitated a threeday business development and entrepreneurship boot camp for shortlisted applicants. The winning health innovation was an unmanned aerial vehicle capable of delivering medical supplies in remote areas and during congested traffic hours in Karachi. Runners-up included an app that can identify blood banks in emergencies, a proposal for EMS response through motorbikes, and
PAKISTAN HEALTH PROGRAMS BY FOCUS Primary and Secondary Care Maternal & Child Health Family Planning & Reproductive Health TB Noncommunicable Diseases HIV/AIDS Malaria 10
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Photo: Sehat Sahulat Clinic Basic+ | Patients waiting for services. 7 8
http://www.unicef.org/infobycountry/pakistan_pakistan_statistics.html http://data.worldbank.org/indicator/SP.RUR.TOTL.ZS
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SOUTH AFRICA COUNTRY OVERVIEW
A LOOK AT THE DATABASE
South Africa is the second largest economy in Africa, with a population of nearly 54 million and a GDP of over 350 billion USD.9 In the last few years, the government has embarked on a mission to launch National Health Insurance across the country to ensure equitable access to quality services for all, but with a history of inequality, a distinctive HIV disease burden, and rising costs of care, this goal is difficult to achieve. With nearly 84% of the population relying on the overburdened and under-resourced public healthcare system and another 68% also purchasing private health services, a gap in access to quality care is created, and the poor are the first to suffer. However, the South African picture is improving. Recent studies have found that new HIV infections have decreased from 6.75% of the population in 2002 to 5.59% in 2015, life expectancy has increased from 51 years in 2005 to 62 years by the end of 2014, and infant mortality rates are on the decline from a peak of 52 deaths per 1,000 live births in 2002 to 32.99 deaths per 1,000 live births by end of 201410, showing the significant strides South Africa continues to make in healthcare.11
Some of the country’s most innovative models were borne out of a need to address its greatest health challenges, including a high HIV prevalence rate (18.9%).12 The CHMI Database profiles 62 programs that operate in South Africa; 40 work in HIV treatment and prevention. Integrated care models in South Africa bring together a variety of services related to diagnosis, treatment, care, rehabilitation, and health promotion, often working across multiple disease-specific interventions, in order to improve efficiency, quality, and access for patients. An example of an integrated care model in South Africa that focuses on both HIV testing and tuberculosis (TB) treatment13 is Kheth’Impilo. The organization specializes in comprehensive testing and treatment for HIV and TB, and has trained hundreds of community health workers through its “Patient Advocate” model. Founded in 2009, Kheth’Impilo has quickly scaled to serve four of nine provinces in South Africa, and has tested hundreds of thousands for HIV and TB. Many primary care models integrate HIV treatment into their services: 35% of South African primary care programs in the CHMI database also provide HIV care, compared to 8.6% primary care programs in the database overall. Unjani Clinics provide low-cost primary healthcare and HIV treatment and counseling. The franchise clinics, constructed from converted shipping containers, are run by female nurse practitioners and serve between 150 to 500 patients per month. The Autonomous Treatment Center is another integrated-care model, providing a onestop-shop of primary care, pre-natal care, prevention of mother to child transmission expertise, on-site pharmacy, and HIV testing and counseling services. Additionally, innovations have responded to the costly and unnecessary referrals experienced by South
Photo: Vula Eye Health | A Vula technician tests the mobile app and peripheral scanning device. http://data.worldbank.org/country/south-africa CIA World Fact book (2015 estimates) 11 http://www.unaids.org/sites/default/files/media_asset/MDG6Report_en.pdf 12 http://data.worldbank.org/indicator/SH.DYN.AIDS.ZS 13 TB also posespose a serious health challenge to South Africa with a rate of 850 TB cases per 100,000 individuals, including drug resistant strains. 9
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Africa’s large rural population. The Vula Eye Health mobile app, for example, was designed to provide rural healthcare workers with the tools and information that would allow them to connect with specialists and make appropriate referrals. Through a relationship fostered by the Bertha Centre, Vula participated in SparkUp!Live, a pitching event hosted by the UCT Graduate School of Business, and received a total of 1.1 million rand (approximately 65,500 USD) as an investment pledge to expand its service offerings.
HEALTH PROGRAM FINANCING IN SOUTH AFRICA 13 REVENUE
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CHMI IN SOUTH AFRICA South Africa’s unique disease profile has created a conducive environment for innovators to try and test models that deliver or increase access to healthcare services. CHMI partnered with the Bertha Centre for Social Innovation and Entrepreneurship, based at the University of Cape Town Graduate School of Business, to surface promising innovations throughout southern Africa, and research adaptable primary care models that could help solve South Africa’s priority health challenges. The Bertha Centre is the first academic center in Africa dedicated to uncovering, connecting, pioneering, and advancing social innovators and entrepreneurs working to generate inclusive opportunities and social justice in Africa.
2 INVESTOR CAPITAL
23 DONOR
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The center recently released the report “Translational Models of Primary Care”, which investigated innovative primary care delivery business mechanisms in Kenya and assessed their translatability to the South African context. The study used CHMI’s adaptation of innovation framework developed in 2014 to understand how the concepts of franchising, incentives, and cross-subsidization could be applied in South Africa.
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SOUTH AFRICA HEALTH PROGRAMS BY FOCUS HIV/AIDS Primary and Secondary Care TB Maternal & Child Health Noncommunicable Diseases Family Planning & Reproductive Health Malaria 10
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NIGERIA COUNTRY OVERVIEW
CHMI IN NIGERIA
Nigeria holds claim to one of the most rapidly expanding health markets in the world. Public health indicators have been slowly improving, with maternal mortality rates dropping and life expectancies rising year by year.14 However, private out-of-pocket spending for health remains high, averaging 70% of total health expenditures. Over the years, CHMI has documented a rising number of innovative approaches operating in Nigeria’s health sector.
CHMI maintains an active presence in Nigeria through the Solina Group. Solina has helped support health innovators by focusing on developing the health marketplace in Nigeria and enabling the scale-up of promising health market innovations.
A LOOK AT THE DATABASE In 2015, CHMI profiled 63 innovative health programs in Nigeria, focusing on a variety of health areas, with 23 providing primary care, 8 focusing on HIV/AIDS, and 11 providing maternal and newborn care. One program in the last category is the Safe Motherhood Program of the University of California San Francisco, which has brought LifeWrap to the Nigerian market. The non-pneumatic anti-shock garment has helped prevent the deaths of thousands of women suffering from postpartum hemorrhage and has been shown to reduce the mortality rate by 48%. Read more in CHMI’s interview with LifeWrap in 2015. Nigeria is inundated with counterfeit medicines from a variety of markets, and many programs profiled in the CHMI database work to combat this challenge. While the public agency charged with tackling counterfeiting NAFDAC (the National Agency for Food and Drug Administration and Control) has made many improvements, private organizations have stepped forward to further protect Nigerians from harmful medicines. Sproxil allows consumers to verify the authenticity of their drugs with the aid of a unique ID entered via SMS on a mobile phone. The program was piloted in Nigeria in 2010 and has since spread across the African continent and to India. Similar programs including mPedigree and DrugStoc rely on mobile technology, and seek to connect anti-counterfeit services with supply chain management systems for hospitals and pharmacies.
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In 2013, Solina Health supported the development of the organizational capacity and strategic vision for the Private Sector Health Alliance of Nigeria (PHN), a new permanent platform for public-private collaboration. The Alliance helps shape Nigeria’s engagement with private sector delivery innovations that directly contribute to achieving national MNCH priorities. As part of this collaboration, Solina worked with the PHN in 2015 to launch the inaugural Health Innovation Challenge Awards. The competition received 330 applications, and 42 shortlisted innovations participated in a business development boot camp in August 2015 that trained applicants on the basics of business development, proposal writing, and financial management. The grand prize went to Fyodor Urine Malaria Test, a low-cost self-administered malaria kit for the quick detection of the P. falciparum antigen through urine, designed for rural areas with a lack of access to health facilities. Other prize winners included Medical Devices as a Service, which provides maintenance, repair, leasing, and financing of affordable medical devices, and e-HEAL, pre-loadable multi-language audio books and posters to increase access to health education among illiterate populations. Two organizations won the CHMI Partnership Award: the Mobile Health Insurance Program for non-electrical specially operated point-of-care haemoglobin meters to increase health insurance coverage; and Omomi, a mobile tool to decrease child mortality by providing mothers with important health information, assisting them in locating health facilities, and connecting them with other mothers online. In total, twelve innovations were selected for incubation and scale up, mobilizing millions in new public and private funding to support emerging approaches. The Health Innovation Challenge Awards aim to not only incubate select innovative solutions, but also to create a robust pipeline of innovations that can be harnessed to advance Nigeria’s MNCH goals.
http://databank.worldbank.org/data/reports.aspx?source=2&country=NGA&series=&period=
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HEALTH PROGRAM FINANCING IN NIGERIA 2 SELF-FUNDED (BOOTSTRAPPED)
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“Nigeria “ is inundated with counterfeit medicines from a variety of markets, and many programs profiled in the CHMI database work to combat this challenge.”
NIGERIA HEALTH PROGRAMS BY FOCUS Primary and Secondary Care Maternal & Child Health Family Planning & Reproductive Health HIV/AIDS Malaria TB Noncommunicable Diseases 10
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Health market innovations have the potential for broader impact, but many face challenges of quality, affordability, and sustainability, which limit their potential to scale and adapt. Promising models seeking to scale require iteration to learn and improve upon their practices. Yet the cost of learning can be steep, and available funding sources do not always align with programs’ learning needs, or enable program managers to take ownership of the learning process. What appears to be missing is a way to connect the dots — an opportunity for programs to work together to tackle common challenges and co-develop practical solutions for implementation. CHMI believes that peer learning and knowledge sharing has the potential to unlock solutions to challenges preventing scale. In an effort to help programs strengthen their models, CHMI has launched a number of new initiatives that support active, collaborative learning and knowledge sharing among profiled innovators. Two of these — the Primary Care Learning Collaborative and Learn and Launch — have brought innovators together in collaborative groups of four or five members to share strategies for improving their models and overcoming operational roadblocks. Others — including the Learning Exchange and the Primary Care Adaptation Partnership—have utilized one-on-one partnerships to promote the adaptation of promising practices across different models and contexts. What these activities have in common is a commitment to collaborative learning, the exchange of tacit knowledge that innovators possess, and a belief in the program manager’s ownership of the learning process.
WHAT ARE CHMI’S LEARNING ACTIVITIES? • The Primary Care Learning Collaborative is a peer-learning network that enables knowledge sharing among primary care organizations on challenges related to quality, sustainability, efficiency, and scale. • The Learning Exchange is designed to enable the scale up, replication, or improvement of CHMI-profiled programs, by allowing programs to engage in a strategic learning activity with a predefined partner. • Learn and Launch is a collaborative learning initiative for CHMI-profiled programs to brainstorm, share, and test practices that will help tackle a specific operational roadblock impeding their growth and scale. • The Primary Care Adaptation Partnership promotes the uptake of promising primary care practices by documenting and transferring active ingredients across program models.
WHAT DO WE KNOW ABOUT HOW PROGRAMS GET TO SCALE? Across different geographies and contexts, programs profiled on CHMI are struggling with similar challenges. Simultaneously, many programs are coming up with innovative solutions to those challenges but lack a way to share “what works” with their peers. Through CHMI’s learning programs, we have worked with participating innovators to document the key lessons learned, ensuring that all programs and stakeholders have access to information on how to strengthen their models, facilitate growth, and encourage adaptation. By disseminating these lessons and enabling more models to learn, CHMI aims to unlock new insights on what holds promise to move the field forward and inform the broader diffusion of innovative approaches and models that address national and global health priorities at scale. We have highlighted many of these lessons in the following chapter. Photo: Jacaranda Health | The CHMI Learn and Launch Africa cohort visits Jacaranda Health to learn about program and facility design
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COMMON LEARNING CHALLENGES AND NEW SOLUTIONS FROM CHMI PROGRAMS HOW DO YOU DESIGN YOUR SERVICES TO SATISFY YOUR MARKET? Customizing your service mix to the specific needs of your target population is the key to sustainability. Often, service providers enter a new market without conducting an in-depth market analysis only to realize that the needs of their prospective patients are different from what they anticipated. • PurpleSource Healthcare recently acquired a chain of seven facilities in Lagos, Nigeria. Each of the facilities has a diverse population surrounding it; one catchment area is over 80% male, while in another, 60-70% of the population is elderly. As a participant of Learn and Launch, PurpleSource is undergoing an in-depth market assessment for its different facilities to more accurately match the health priorities of the surrounding community in its service offerings. • Quinta Bonita provides mental health services to underserved populations in Mexico through an innovative virtual consultation model. They found that their mental health patients were also searching for primary care services at an affordable cost. As a result, Quinta decided to add primary care services to their model. Through the Primary Care Adaptation Partnership, Quinta Bonita is working with Ross Clinics, a family doctor model in India, to adapt their primary care model to the Mexican market.
• Penda Health in Kenya has dramatically evolved their service offerings over time to reflect patient needs. Through the Primary Care Learning Collaborative, Penda Health adopted a number of new practices to increase its service offerings. Following an idea from Ross Clinics, Penda has implemented dental services in their clinics. They are using pricing “discounts” to drive patient volumes and have also incorporated task shifting to increase pricing efficiencies.
HOW DO YOU RECRUIT, TRAIN AND MOTIVATE YOUR STAFF? A trained and motivated workforce is a critical component of any successful healthcare program, but recruiting the right staff can be challenging. In particular, hiring and motivating your non-clinical workforce can be a new challenge for program managers with a clinical background. • MicroClinic Technologies in Kenya developed Zidi, a technology that streamlines operational processes and report generation, but faced challenges in scaling the technology among clinical providers. They partnered with GlaxoSmithKline Kenya and Spartan in South Africa through a CHMI Learning Exchange to develop a strategy that would lead to increased adoption of Zidi through social marketing and youth sales agents, called Blue Angels.
Photo Left: SalaUno | The waiting area in one of SalaUno’s facility in Mexico City. Photo Middle: Ross Clinics | Dr. Devashish Saini discussing primary care services with a father and son. Photo Right: Access Afya | Woman buying products from the Access Afya pharmacy.
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MicroClinic learned that their target clinics needed more than sales representatives—they also wanted technical support in order to implement the product. Now, MicroClinic has re-defined their Blue Angels to serve as Health IT consultants, who can both sell the technology and provide support to clinic managers to generate increased health impact.
HOW DO YOU INCREASE THE DEMAND FOR HEALTH SERVICES IN UNDERSERVED POPULATIONS?
• MobiCURE’s OMOMI mobile platform enables mothers and expectant mothers in Nigeria to monitor their children’s health and access MNCH information. Their sales team of “foot ambassadors” register women for services at clinics and during market days. During Learn and Launch, MobiCURE indicated they wanted to better connect their sales incentives to their impact targets. They are now changing the remuneration package for foot ambassadors to a bonus model based on the number of women registered.
• Care2Communities in Haiti and Access Afya in Kenya were both struggling to drive demand for primary healthcare in their communities and wanted to test which marketing efforts increase primary care uptake. Through a research initiative that identified how customers view their brand, they identified two gaps in their outreach efforts. For Access Afya, located deep in informal settlements, they improved their signage to help new patients locate the clinic; Care2Communities used coupons to encourage new patients to try their services.
• iKure Techsoft and Amader Haspatal in India realized the role technology could play to increase operational efficiency and expand existing primary care services to include MNCH services for pregnant women. Through their Learning Exchange partnership, 10 new community health workers (CHWs) in West Bengal were trained to conduct continuous monitoring of MNHC indicators for 90 rural villages. CHWs were trained to use iKure’s point-of-care IT platform to input data and monitor clinical protocols. By providing CHWs with the tools to be successful, iKure was able to train a new team of highly motivated community women to provide MNCH monitoring to hard-to-reach patients.
HIGHLIGHTS: FINDINGS FROM 2015
Driving demand for health services can be a challenge, particularly with patients who are highly price sensitive. Often, a successful marketing strategy needs to incorporate traditional branding and awareness with health education and awareness campaigns.
HOW DO YOU ADAPT HIGH QUALITY CLINICAL STANDARDS TO A LOW-RESOURCE SETTING? Quality assurance is one of the most important, yet challenging, aspects of clinical care. CHMI programs around the world are looking to some of the field’s pioneering leaders in low-cost innovation to understand what works in low-cost, high-quality clinical delivery. • SalaUno, an affordable eye care service provider in Mexico, was modeled after Aravind Eye Care in India, but the program was still working to customize and adapt Aravind’s
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standardized quality management processes in Mexico. Through the Learning Exchange, Aravind clinical staff recommended that SalaUno streamline their pre-surgery protocol and criteria, which has reduced their surgical response time to three days. Additionally, SalaUno has modified their counselor process for surgery recommendations; uptake of these services by patients has increased from 50% to 70%. • LifeNet International in Burundi and Health Builders in Rwanda used the Learning Exchange to explore the differences in their approach to clinical and health management evaluation techniques. Both programs use quality scorecards to rate clinical and management systems, but found that their scorecards’ focuses were contextdependent and spoke to the programs’ overall goals. By adopting elements of the other’s evaluation practices, the programs were able to make recommendations to improve health facilities in their regions of operation. • Afghanistan has made significant strides in increasing diagnosis and treatment of TB, but tracking patients and drug adherence remain constant challenges. To increase quality management of TB cases, the Afghan Community Research & Empowerment Organization for Development (ACREOD) partnered with Operation ASHA to adapt their urban TB control program from India to Afghanistan. Operation ASHA trained ACREOD staff on their tablet-based technology program, which uses fingerprint scanners to track patient visits. A pilot of the model has been started
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in Kabul and ACREOD staff believes that by enabling patients to take their TB medicine conveniently, without sacrificing time and money on transport, they will improve patient compliance with treatment.
““ULTIMATELY, THE OPPORTUNITY FOR SMALL AND INNOVATING ORGANIZATIONS TO LEARN FROM AND WITH PEER ORGANIZATIONS IS INVALUABLE. BY SERVING [BASE OF THE PYRAMID] POPULATIONS, WE’RE DOING SOMETHING CHALLENGING AND NEW AND WITHOUT EASY ANSWERS. SHARING EXPERIENCES, QUESTIONS, AND STRATEGIES WITH A COLLABORATING PARTNER ADVANCES THE WAY WE THINK ABOUT OUR WORK AND EXPERIMENTING TOGETHER PUTS OUR QUESTIONS AND ANSWERS INTO CONTEXT” ——Allison Berry, Care2Communities
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HOW DOES CHMI APPROACH ADAPTATION? Through CHMI’s Learning Initiatives, we have seen that programs are searching for opportunities to transfer and adapt innovations. We also found that many of the partnerships created between innovations connected through CHMI were asking the same question: what are the aspects of a program that can be isolated and analyzed for adaptation to address a similar problem in a different context? CHMI developed the Adaptation Framework for Global Exchange of Innovation to provide a set of flexible guiding principles for identifying program activities that have the potential for impact. It guides users to crack the program open and look at the core program attributes crucial to achieving the program’s outcomes — what we call the “active ingredients”. Explore the framework. As we continue to connect innovators to each other, and to researchers, funders, and policymakers, the question of adapting innovations between contexts becomes even more relevant. The collaborative learning model has become widely accepted in promoting innovations through many sectors, and we encourage organizations to continue connecting great models and great ideas. Our past learning activities and the Adaptation Framework have proven that allowing program managers to set the agenda for the learning process allows for experimentation and resulting success in achieving scale.
Photo Left: LifeNetInternational | Health workers at a clinic affiliated with LifeNet International in Burundi. Photo Top Right: iKure Techsoft | Mobile phone platforms are emphasized at a training program for iKure’s Community Health Workers. Photo Bottom Right: TotoHealth | A user of TotoHealth’s platform.
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LEARNING AND ADAPTATION ACTIVITIES PRIMARY CARE LEARNING COLLABROATIVE Access Afya LifeNet International Penda Health Ross Clinics Swasth Health Centre
LEARN AND LAUNCH LEARNING EXCHANGE
Ayzh
Access Afya
doctHERS
ACREOD
iKure Techsoft
Care2Communities
LifeCircle Senior Services
GroupeSOS
MOBIcure
Health Builders
PACE
Kano State Primary Healthcare Management Board
PurpleSource Healthcare
Kenya Community Media Network
TotoHealth
Swasth Health Centers
Last Mile Health LifeNet International
PRIMARY CARE ADAPTATION PARTNERSHIP
MicroClinic Technologies
Jacaranda Health
Operation ASHA
HLFPPT - Merrygold Health Network
Organic Health Response
Healthy Entrepreneurs
Possible Health
Safe Mothers Safe Babies
SalaUno
Ross Clinics
Spartan
Quinta Bonita
LifeCircle Senior Services
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TRACKING PROGRAM PERFORMANCE 34
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Funders, researchers, program managers, and policymakers around the globe are seeking better information on promising approaches to make healthcare more accessible and affordable to the poor. CHMI closely tracks programs engaged in sharing detailed information on their innovations through the Reported Results Initiative, CHMI Plus, and our Monitoring and Evaluation Badges system. Photo Left: Organic Health Response | Community health workers being trained to provide education training to our micro clinic support groups. Photo Below: BanaPads | Women and girls holding BanaPads sanitary pad products.
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TRACKING PROGRAM PERFORMANCE
REPORTED RESULTS INITIATIVE CHMI’s Reported Results Initiative is designed to surface programs that have active monitoring and evaluation systems and are tracking their impact.
The Reported Results Initiative allows program managers to provide clear, quantifiable, and time-bound measures of program performance across ten key categories in three domains: • HEALTH ACCESS | Affordability, Availability, and Pro-Poor Targeting • OPERATIONS/DELIVERY | Clinical Quality, Efficiency, Financial Sustainability, User Satisfaction • HEALTH STATUS | Health Output, Health Outcome, and Population Coverage Since launching the initiative in 2011, more than 358 programs have reported results across the various categories, with the majority of results being reported in Health Outcome, Health Output, and Population Coverage.
PROGRAMS FROM CHMI’S DATABASE REPORTING RESULTS IN KEY PERFORMANCE DIMENSIONS: Health Output Affordability User Satisfaction Clinical Quality Pro-Poor Targeting 30
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Health Output is a measure of the number of health services or products provided or clients served in a given time period. • Kangu is a crowd-funding web platform that allows users to fund healthcare services for pregnant mothers around the world. Kangu reported that between January 2013 and September 2015, 742 pregnant women in need have received at least 1 antenatal care visit and that there have been 0 maternal deaths for women whose pregnancy-related costs have been funded through Kangu. Affordability is a measure of patients’ ability to pay for a given product or service and can serve as a measure of access. • LifeCircle Senior Services team of nurses and caregivers provides subscription based home nursing services to senior citizens in India. LifeCircle has reported to CHMI that from April 2014 to March 2015 they offered their services at approximately 30% lower cost than market prices. By partnering with donors, LifeCircle has also been able to offer services to poor patients for free. Availability is the quantitative evidence on the ability of patients to access health products/services as a result of the program, including both physical access and service availability. • Nayana Advanced Eye Treatment Units are facilitating more locations for individuals to receive diabetic retinopathy and glaucoma treatment. The long distances needed to travel in Karnataka, where the program operates, in order to reach facilities with necessary equipment for treatment of these diseases, such as angiographs and lasers, has often reduced patients ability to seek care. The Nayana Advanced Eye Treatment Units were designed to transport highly sensitive medical equipment for the treatment of retinopathy and glaucoma so that they can be shared between remote basic ophthalmology centers in Karnataka, turning them for a day to several days into a center for advanced eye care. From June, 2014, to March, 2015, Nayana has increased the number of centers which are able to offer advanced eye care from 6 to 48.
Photo Left: Biocon Foundation | Preventative health education sessions led by a community health worker. Photo Top Right: Sevamob | Sevamob offers mobile and point-of-care healthcare services and pharmaceutical products. Photo Bottom Right: LifeCircle Senior Services | A nurse trained by LifeCircle updates a patient’s care plan in their home.
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TRACKING PROGRAM PERFORMANCE
PROGRAM COMPLETENESS: CHMI Plus provides programs an opportunity to shine by sharing as much information about their program as possible. The CHMI Plus Profile Completeness Scale awards programs points for answering questions about their program’s model, location, reported results, and other basic information. Programs which have provided a significant amount of information about their model are awarded Bronze, Silver, and Gold CHMI statuses. Bronze level program profiles gain increased web visibility on the CHMI home page, topic portals, and publications. Silver level programs are often nominated for competitions led by partnering funders (I.e. GlobalGiving, Skoll Foundation, etc.) and maintain the benefits of bronze programs. Gold level programs are considered for in-depth learning and funding opportunities, including CHMI’s Learning Exchange and the Primary Care Learning Collaborative, and are also eligible for benefits of Silver and Bronze Programs.
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580 BRONZE PROGRAMS Bronze level program profiles gain increased web visibility on the CHMI home page, topic portals, and publications.
280 SILVER PROGRAMS Silver level programs are often nominated for competitions led by partnering funders (I.e. GlobalGiving, Skoll Foundation, etc.) and maintain the benefits of bronze programs.
109 GOLD PROGRAMS Gold level programs are considered for in-depth learning and funding opportunities, including CHMI’s Learning Exchange and the Primary Care Learning Collaborative, and are also eligible for benefits of Silver and Bronze Programs.
HealthMarketInnovations.org
MONITORING AND EVALUATION BADGES: Many programs in the CHMI database choose to share their impact information in the more comprehensive context of their impact or progress reports. Programs are now able to directly upload their monitoring and evaluation documents to their profiles so that researchers, funders, and award groups can easily download and review documentation on their impact and discover programs that are committed to learning and improvement. To date, the CHMI Database contains 13 documents on the strategies programs use for their data collection, 48 process evaluations, and 55 impact evaluations.
13
DATA COLLECTION STRATEGIES
48
PROCESS EVALUATIONS
55
IMPACT EVALUATIONS
Photo: Access Afiya | Access Afya’s street-side pharmacy in Nairobi.
HIGHLIGHTS: FINDINGS FROM 2015
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CHMI’S IMPACT AND LOOKING FORWARD 40
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In early 2015, CHMI underwent a strategic review of its first five years conducted by an independent evaluator in close collaboration with our funders, UK Aid and the Bill and Melinda Gates Foundation. The strategic review process was a great opportunity for all of us to reflect on our work over the past five years and look objectively at what we have accomplished and learned, and where we can go in the future. The review found that CHMI continues to be highly relevant and that it has facilitated real results in terms of policies and practices, with strong potential for long-term impact. We are excited to share some highlights from our review and share our ideas for where we can take CHMI in the future. Photo Left: TotoHealth | A mother checks the TotoHealth mobile platofm. Photo Below: TeleRad Foundation | A nurse checks a patient’s vital signs at a primary care center with a telemedicine system.
HIGHLIGHTS: FINDINGS FROM 2015
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CHMI’S IMPACT AND LOOKING FORWARD
WHAT HAVE WE LEARNED KNOWLEDGE SHARING IS EFFECTIVE AND VALUABLE To date, over 700,000 unique users have visited the CHMI website, with about 55% of these visits coming from low and middleincome countries. The review team found that CHMI is considered a global knowledge hub for innovators, includes a range of health topic innovations, and offers a great deal of information with minimal barriers to entry.
““THE CHMI WEBSITE IS ONE OF THE REASONS WHY WE ARE KNOWN OUTSIDE INDIA. WE HAVE BEEN RECEIVING INQUIRIES FROM HOSPITALS AND INDIVIDUALS OUTSIDE INDIA TO KNOW MORE ABOUT THE REMEDI TELEMEDICINE KIT.” ——Rajeev Kumar, cofounder, Neurosynaptic, India
Photo Top Left: D-Tree International | A Community Health Worker in Zanzibar counseling pregnant woman using D-Tree International’s phone-based decision support tool. Photo Left: Dr. John Ly, Last Mile Health Medical Director, reviews a child’s vaccination record with Aaron Garley, Community Health Worker Leader, in the community of Billibo in Konobo District, Liberia. Photo Top Right: CHMI | Learn and Launch brings programs together to discuss shared challenges to health service delivery.
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HealthMarketInnovations.org
To date, over 700,000 unique users have visited the CHMI website, with about 55% of these visits coming from low and middle-income countries.
OUR NETWORK OF PARTNERS INFORMS POLICY AND PRACTICE TO SHAPE HEALTH MARKETS
COLLABORATIVE LEARNING HOLDS GREAT PROMISE IN PROMOTING SCALE UP AND ADAPTATION
One of CHMI’s greatest assets is its global network of partners, which allows CHMI to be flexible and responsive to the needs of countries and innovators working to improve health systems around the globe. This partner network has shown great success in cross-fertilizing ideas between geographic regions, facilitating exchanges of best practices among programs, and providing a better understanding of the landscape of innovative models that can meet governments’ national health priorities.
CHMI leads activities that allow for the sharing of ideas and experiences, testing of new approaches, and sharing the results to enable successful innovations to spread more rapidly between organizations and across geographies. These initiatives have resulted in valuable insights, lessons learned, and practical recommendations for improvement and adaptation. The broader lessons from these activities are disseminated to ensure that many more are benefiting from the knowledge generated.
““ WE CANNOT QUANTIFY THE INPUT TO OUR BOTTOM LINE, BUT WHAT I CAN SAY IS THAT WE REALLY APPRECIATE THE WORK THAT CHMI AND ACA DO. THEY HAVE REDUCED OUR COST OF COLLABORATION, HELPING US MAKE LINKAGES WE WOULD OTHERWISE NOT HAVE BEEN ABLE TO DO.” ——Moka Lantum, Program Manager, MicroClinic Technologies
HIGHLIGHTS: FINDINGS FROM 2015
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CHMI’S IMPACT AND LOOKING FORWARD
WHERE DO WE GO FROM HERE? CONTINUE TO EVOLVE CHMI’S GLOBAL DATABASE
FACILITATE THE GLOBAL ADAPTATION OF PROMISING PRACTICES
CHMI will continue to refine its data collection methods — including offering benefits to programs who self-report their impact under the CHMI Plus system — and make the website easy to navigate for program managers, researchers, and funders.
In 2015, CHMI launched the Adaptation of Innovation Framework, which helps program managers identify the “active ingredients” that make their programs successful. In late 2015, CHMI launched two new learning initiatives based on the concept that these active ingredients can help facilitate the scale up of programs in new geographies. In the years to come, CHMI hopes to introduce more learning and knowledge sharing initiatives that promote the diffusion of promising models and result in broader learning opportunities for the entire field.
ENGAGE POLICYMAKERS TO IMPROVE HEALTH MARKETS CHMI’s country partners have increasingly worked closely with policymakers to foster stronger collaboration among governments and innovators looking to improve and scale their services. CHMI will build on this strong foundation and continue to inform policy and practice through its initiatives that advance government engagement with health market innovators, link to public finances, and generally foster increased public stewardship of the entire health market. Photo Top: OrganicHealthResponse | OHR’s Health Navigators are a group of community health workers trained in patient advocacy, basic first aid, and health navigation between health facilities. Photo Above: CCBRT | One of the CCBRT team testing a new prosthetic limb before use in CCBRT’s state of the art Prosthetics & Orthotics workshop.
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PROGRAMS MENTIONED IN THIS REPORT The majority of programs selected for this report, and for other benefits, are those with a CHMI Plus “GOLD” rating. These programs share updates on their activities and results, and share Monitoring and Evaluation information to help others improve.
100% Jeune, 11
Nayana Advanced Eye Treatment Units, 37
Access Afya, 29, 32, 39
Omomi, 24, 29
Al-Shifa Trust, 20
Partners In Reproductive Health, 11
AMD’s Dispatch Case, 9
Penda Health, 28, 32
Autonomous Treatment Center, 22
Possible Health, 8, 32
BanaPads, 10, 33
Project Khuluma, 11
Bluestar Pilipinas, 13
PurpleSource Healthcare, 28, 32
Care2Communities, 29, 30, 32
Quinta Bonita, 28, 32
Comprehensive Community Based Rehabilitation in Tanzania, 2, 13
ReliefWatch, 8
Deen Dayal Chalit Aspatal, 16
SalaUno, 13, 29, 32
Dengue Fever Insurance Card, 13
Sehat Sahulat Clinic Basic+, 20
DoctHERs, 20, 32
Sevamob, 17, 37
DrugStoc, 24
Sizophila Project, 11
D-Tree International, 5, 13, 43
Smart Mobile, 9
Health Builders, 30, 32
Sproxil, 24
Heartfile Health Equity Financing, 20 I-Care, 10
Surveillance in Post Extreme Emergencies and Disasters SPEED, 8
iKure Techsoft, 29, 31, 32
Telerad Foundation, 6, 16, 41
Kangu, 37
The Youth Truck, 10
Karuna Trust, 17
TotoHealth, 18, 31, 32, 40
Kheth’Impilo, 22
Unjani Clinics, 22
Last Mile Health, 8, 32, 42
Using Your Hands to Talk about Sex, 11
LifeCircle Senior Services, 17, 32, 37
Viva Afya, 18
Lifeline Express Hospital Train, 16
Vula Mobile app, 23
LifeNet International, 30, 32
WelTel, 18
LifeSpring Hospitals Private Limited, 16
Window of Love, 11
LifeWrap, 24
World Health Partners, 16
Matibabu Foundation, 11
Youth Cafe, 11
M-Chango, 18
ZanaAfrica, 10
Ross Clinics, 16, 18, 32
MEDA Bednets, 12 Media Campaign PULIH, 9 MicroClinic Technologies, 28, 32, 43 MicroEnsure, 18 Microinsurance Catastrophe Risk Organization (MiCRO) Cholera Product, 9 mPedigree, 13, 24 NAFDAC, 24 Nairobi Slums TB Project, 18 Nationwide, 17
HIGHLIGHTS 2015
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INFORMING + CONNECTING
ALL THOSE WHO STRIVE TO IMPROVE THE HEALTH OF THE WORLD’S POOR. HealthMarketInnovations.org